The General Public Vastly Overestimates Primary Care Spending in the United States

INTRODUCTION

The United States has chronically underinvested in primary care. Despite its foundational importance to health outcomes,^1,2 primary care accounts for only 4.7% of national health care expenditures.³ Several states have recently taken steps to address this issue by pursuing legislation to measure and increase primary care spending.^4,5 Public support is crucial for enacting policies to increase primary care investment. Public understanding of primary care spending in the United States, however, remains poorly characterized. We conducted a novel survey to assess public perceptions of primary care expenditures.

METHODS

We contracted with SurveyMonkey (Symphony Technology Group) to administer an English-language online survey using SurveyMonkey Audience, a service that connects volunteers who receive survey invitations with researchers who seek a pool of survey respondents from the general public with characteristics matching study needs. SurveyMonkey Audience has been utilized in previous peer-reviewed studies to assess perspectives of survey respondents selected to fit study criteria.^6,7 We requested a target sample of 1,000 respondents, aged ≥18 years, residing in the United States, sampled to reflect the demographic distribution of the US adult population and to minimize duplicate respondents or contamination by bots. The demographic distribution of respondents was compared with US census data to verify sample demographics were reasonably aligned (Table 1).⁸ The survey was conducted in June 2024.

Survey items were designed to replicate a public opinion survey conducted in Australia,⁹ with questions preceded by a definition of primary care. Respondents were asked to estimate the percentage of Americans’ total health care needs addressed by primary care, to estimate the percentage of total US health care spending funding primary care, and to rate the importance of primary care to the overall functioning of health care (1-10 Likert scale anchored at “not important” and “very important”). Descriptive analyses were conducted in Excel (Microsoft Corporation). The study protocol was reviewed by the Virginia Commonwealth University IRB and determined to be exempt.

RESULTS

The characteristics of our 1,135 survey respondents are shown in Table 1. Respondents estimated that primary care addresses 58.7% (95% CI, 57.4%-59.9%; SD 22.2; interquartile range [IQR] 28.5) of US health care needs. The mean estimated percentage of health care spending allocated to primary care was 51.8% (95% CI, 50.3%-53.2%; SD 24.8; IQR 40), with a median estimate of 50% (Figure 1). The mean rating of the importance of primary care to overall health care function was 8.0 (95% CI, 7.8-8.1; SD 2.1; IQR 3).

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Figure 1.

Comparison of the Public’s Estimated Health Care Needs Addressed by Primary Care and Estimated PC Spend vs Actual PC Utilization and Expenditure in the United States

PC = primary care.

DISCUSSION

Our findings reveal a significant discrepancy between public perception and actual allocation of health care expenditures to primary care. On average, respondents overestimated spending by more than 10-fold compared with current estimates of actual primary care spending (4.7%).³ Although IQR for estimated primary care expenditure demonstrated some variation in responses, the first quartile estimate of 31% still greatly overestimates primary care spending. Respondents indicated that primary care is very important to US health care, and respondents’ mean estimates that about one-half of all health care needs are addressed by primary care were very close to actual primary care utilization as a percentage of all ambulatory physician visits in the United States (50.3%).¹⁰ These results highlight the stark disparity between current levels of primary care investment and the public’s perception of primary care importance, utility, and expenditure. A survey in Australia also found the public overestimated primary care spending, though to a lower degree.⁹

A study limitation is the potential non-representativeness of the sample. Although individuals volunteering for Survey-Monkey Audience likely differ from the general population on unmeasured characteristics such as health and digital literacy, the demographic characteristics of respondents closely mirrored the US adult population. Our results for public views on needs addressed by primary care and its importance are similar to findings from published public surveys in the United States and Australia, suggesting our sample did not disproportionately include individuals with an exceptionally favorable perception of primary care that might bias perception of spending.⁹ Although the survey included a definition of primary care, public understanding may differ from definitions used by researchers measuring primary care spending; respondents may count services in their estimates that are not part of conventional definitions. Additionally, our survey did not include qualitative methods. Future studies would benefit from a mixed methods approach to explore how respondents formulate their estimates.

While acknowledging a degree of imprecision in our results, we believe it is reasonable to conclude the public believes that the nation invests a substantially greater share of the health care budget in primary care than is the actual case. Yet in contrast to the public’s high regard for primary care and commensurate expectations of primary care expenditure, primary care access, utilization, and spending have been decreasing nationally.³ Chronic underinvestment in primary care has resulted in workforce shortages, physician burnout, reduced access, and suboptimal care.² Access to high-quality primary care has been associated with better population health and more equitable outcomes, and The National Academies of Sciences, Engineering, and Medicine’s Committee on Implementing High-Quality Primary Care has described primary care services as a common good, calling for greater investment in primary care.² A growing number of states have taken steps to achieve this by enacting legislation and implementing regulations to increase primary care spending, indicating political will to rebalance health care spending priorities.⁵ The substantial overestimation of primary care spending by the public highlights the need for increased patient and public engagement and education to rally additional state and national support for policy change that affirms the essential role of primary care in the health care system.